Provider Demographics
NPI:1659313658
Name:SMITH, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1200 6TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2369
Mailing Address - Country:US
Mailing Address - Phone:231-935-5800
Mailing Address - Fax:231-935-5822
Practice Address - Street 1:1200 6TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-935-5800
Practice Address - Fax:231-935-5822
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301055166207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060B86046OtherGROUP BLUE SHIELD NUMBER
MI2753469Medicaid
MI3686012Medicare PIN
MI060B86046OtherGROUP BLUE SHIELD NUMBER
MIE19817Medicare UPIN